Stanford
Office of Risk Management and Insurance

Forms and Notices

DocumentPurposeTimelineCompleted bySend to
Time of Hire PamphletNotifies new employees about California Workers’ Compensation rights and benefits.  Ensures employees know what to do in case of workplace injury.Either at the time of hire or by the end of the first pay period  NA         NA
Workers’ Compensation PosterOutlines employee benefits under Workers’ compensation   NA NA        NA
Personal Physician Pre-Designation FormAllows an employee to pre-designate a personal physician for treatment of work-related injuries or illnesses   NAThe employee and the doctor.  Primary Treating Physician must agree.        NA
eSU-17 (complete electronically on the EHS website)

To be completed for any on campus injury, illness, accident or exposure involving a Stanford University employee or working student.

**Except for incidents related to stress or mental health**

To be completed within 24 hoursSupervisor & Injured Worker

Complete elecronically on the EHS website

 

eSU-17B (complete electronically on the EHS website)It is to be completed for any on campus injury, illness, accident or exposure involving a person other than a Stanford employee.To be completed within 24 hoursInvolved Party &/or University ContactComplete electronically on the EHS website
State Form DWC-1This form notifies employees of their right to file a Workers’ compensation claim. They may file by completing and signing the form.To be provided to the employee within 24 hours or one working day of notice or knowledge of injurySupervisor or Department Administrator per first page instruction sheet. Employee completes and signs only if filing a claim.

"SECURE: Email to Risk Management at: incidentreport@stanford.edu or workerscomp@stanford.edu".

 

CAL OSHA 5020Completed (must be typed) when one or more workdays are lost or when treatment is provided in a medical facility.Submitted to Risk Management within 48 hoursSupervisor, HR, or  department Administrator (Not  completed by the employee)"SECURE: Email to Risk Management at: incidentreport@stanford.edu or workerscomp@stanford.edu".